QIIG # (updated or new date)



HEALTH SERVICES QUALITY ASSURANCE IMPLEMENTATION GUIDE

EXERCISE 39 (05/10)

SUBJECT: DENTAL CLINIC POLICIES AND PROCEDURES MANUAL

REFERENCE(s): COMDTINST M6000.1.D

PURPOSE: The dental clinic policies and procedures manual is a guide to the daily operation of the clinic. It provides a concise reference for orientation of new personnel to the clinic and is a source of information in the absence of the regular clinic staff. This reference shall be developed and maintained by the Senior Dental Executive (SDE) or his/her designee.

DISCUSSION: Enclosure (1) provides a sample of a dental clinic policies and procedures manual. Sections required include mission and departmental organization; duties of the Senior Dental Executive (SDE), Senior Dental Officer (SDO), Dental Officer (DO), Duty Dental Officer (DDO), Health Services-dental technician (HS), other HSs, Dental Hygienist; general regulations, scheduling, after-hours dental emergencies, reports, preventive maintenance, dental supply, and medical emergencies in the dental clinic. Using this sample in developing the manual will ensure that the manual meets clinic needs while covering required topics. Specifics with regard to policies and procedures themselves will necessarily vary by clinic and may need a more extensive explanation than used in this sample. Factors affecting local policies include clinic mission, makeup of beneficiary population, and proximity of military and other referral services. The manual must be updated annually or more frequently if necessary. Annual revisions shall be annotated, dated, and signed on the cover page.

ACTION: Dental clinics shall have a clinic policy and procedures manual which will be updated annually or more frequently if necessary. Enclosure (1) may be used as a sample for the content of this document.

ENCLOSURE (1): Sample Dental Clinic Policy and Procedures Manual

Enclosure (1)

SAMPLE

U.S. COAST GUARD HEALTH CARE FACILITY

YOUR CLINIC NAME/LOCATION HERE

DENTAL CLINIC POLICY AND PROCEDURE MANUAL

(Signature and date below to indicate policy has been reviewed and/or updated)

______________________________________________________

Signature/Date (Senior Health Services Officer)

______________________________________________________

Signature/Date (Designated Dental Officer)

DATE OF ISSUE

ANNUAL

(Signature and date below indicates the policy has been reviewed)

REVIEWED/REVISED ______________ _______________

SIGNATURE DATE

______________ _______________

SIGNATURE DATE

Table of Contents

I. Mission and Organization

A. Mission

B. Beneficiaries

C. Space Available

D. Billets

II. Duties and Responsibilities of Personnel

A. Duties of the Senior Dental Executive (SDE)

B. Duties of the Senior Dental Officer and Dental Officer (SDO/DO)

C. Duties of the Duty Dental Officer (DDO)

D. SDE/SDO Delegation of Duties

E. Duties of the Health Services (HS)/Civilian Personnel

F. Duties of the Dental Hygienist

III.Dental Clinic Policies and Procedure

A. Dental Clinic Protocols

1. Daily Weekly Monthly Quarterly Routine

2. Emergency Visit Procedures

3. Appointment Procedures

4. Medical Emergencies (including incapacitated provider protocol)

5. After Hours Emergencies

6. Active Duty Referrals

7. Dental Radiology

8. Digital Dental Radiology

9. Mercury Hygiene

10. Dental Supply

B. Treatment Protocols

1. Anxiolysis

2. Implants

3. Preventive Dentistry Program

4. Prosthodontic Dentistry

5. Treatment of Aviation Personnel

6. Treatment of Minors

C. Administrative

1. Leave and Liberty

2. Dental Extern Program

DENTAL CLINIC POLICIES AND PROCEDURES

I. MISSION AND ORGANIZATION

A. Mission

The mission of the Dental Clinic is to support the Health and Safety Worklife Support Activity (HSWL), the District Field Office, the local Command, and our members. The goals of the dental clinic are the prevention of oral disease, orofacial injury and deleterious oral conditions, the elimination/reduction of existing disease, and the restoration of diseased and injured tissue to proper function, consistent with the needs of the service.

B. Beneficiaries

The dental clinic’s primary beneficiaries are Coast Guard personnel assigned to the unit (name here). Active duty members of other Uniformed Services will be treated to the fullest extent possible. When space is available, the clinic shall offer dental care (in order of priority) to:

1. Dependents of Active Duty members not enrolled in the TRICARE Dental Plan (TDP).

2. Retired personnel (regardless of enrollment status in the TRICARE Retiree Dental Plan).

3. Dependents of retired personnel (regardless of enrollment status in the TRICARE Retiree Dental Plan).

C. Space Available Care

When space available care is offered to non-active duty personnel, it shall be prioritized as follows:

1. Preventive Care

2. Restorative Care

3. Complex Care, for:

a. Dependents of active duty

b. Retirees

c. Dependents of retired personnel may receive preventive and restorative care only and are encouraged to enroll in TDP.

D. Billets

The dental clinic is authorized;

1. The following uniformed billets:

a. One Senior Dental Executive (SDE)- at Field Offices

b. One Senior Dental Officer (SDO)

c. (#) Dental Officers (DOs)

d. (#) Chief Health Services Technicians (HSCs)

e. (#) Health Services Technicians (HSs)

2. Civilian (civil service) positions: (list here)

3. Contract providers or positions: (list here)

4. Extern agreements: (list here)

II. DUTIES AND RESPONSIBILITIES OF PERSONNEL

A. Duties of the SDE

The duties of the SDE are listed in the Medical Manual (COMDTINST M60001.D).

They include, but are not limited to:

1. Management of the quality of dental care provided.

2. Oversight of the cleanliness and working conditions of the clinic and its equipment.

3. Coordination of dental services with those of the clinic overall, HSWL SUPACT, the Field Office (FO), and the local Command.

4. Training, direction and coordination of personnel assigned to the dental clinic.

5. Those clinical duties assigned to DOs (below).

B. Duties of the SDO and DO

The duties of the DOs are listed in the Medical Manual (COMDTINST M60001.D) are:

1. Ensuring the fitness for unrestricted duty of active duty personnel on a worldwide basis.

2. Prevention and treatment of diseases, impairments and injuries of the teeth, jaws, and related structures.

3. Prioritizing the delivery of dental care to meet Coast Guard unit operational readiness requirements.

C. Duties of the Duty Dental Officer (DDO): The DDO is required to treat active duty personnel who experience after-hours dental emergencies. Additionally, the DDO is required to treat active duty dependents and retirees who are currently under treatment and who exhibit dental emergencies related to their treatment by DOs or dental externs

D. SDE/SDO Delegation of Duties

1. Screen and triage emergency/sick call patients for DOs.

2. Supervise, advise, and train HSs assigned to the dental clinic.

3. Facilitate ongoing record review and ensure dental record accountability.

4. Supervise appointment system.

5. Assist in the arrangement of consultation appointments.

6. Provide all dental clinic reports.

7. Maintain and update correspondence files.

8. Oversee the preventive maintenance program for dental clinic equipment.

9. Manage the dental supply system and prepare the annual budget for dental supplies and equipment.

10. Expose and manage dental radiographs.

11. Coordinate the dental extern schedule.

12. Supervise cleanliness of dental clinic at all times.

13. Keep SDE informed of clinic problems and recommended changes.

14. Maintain biopsy, consult and lab logs.

15. Maintain Material Safety Data Sheets (MSDS) file and oversee Occupational Safety and Health Administration (OSHA) Communication requirements.

16. Ensure dental encounters are accurately documented via appropriate medical information systems, Dental Common Access System (DENCAS).

17. Monitor infection control practices in the clinic.

18. Monitor the dental radiology program and ensure compliance.

19. Maintain an inventory of major and minor dental equipment.

20. Maintain monthly recall system for dental readiness.

21. Maintain Quality Implementation Studies (QISs).

22. Maintain and update the Dental Clinic Policy and Procedure Manual.

23. Maintain Patient Satisfaction Survey Program.

E. Duties of HS/Civilian Personnel

The duties of HS and civilian personnel are listed in the Medical Manual (COMDTINST M60001.D) and include:

1. Provision of supporting services to dental officers and patients.

2. Instrument preparation, including cleansing, sterilization, packaging, sharpening, distribution, and storage.

3. Following manufacturer's instructions for maintenance of handpieces, sonic instruments, dental units, laboratory equipment, and sterilizers.

Instructions are kept at ____ (location) ______.

F. Duties of the Dental Hygienists

1. The duties of Dental Hygienists include:

a. Providing prophylaxis, scaling, and root planing therapy to assigned patients.

b. Exposing and processing radiographs.

c. Maintaining proper infection control procedures.

d. Providing oral hygiene instruction and nutritional counseling.

III. DENTAL CLINIC POLICIES AND PROCEDURES

A. Dental Clinic Protocols

1. Daily, Weekly, Monthly and Quarterly Routine.

The daily, weekly, monthly,

a. Clinic Hours: ____ to ______.

b. Sick call: ____ to _____

c. Dental Exams: ____ to _____.

d. Training:__ to ____ on ___ (day) _____.

e. ______ (other) __________.

2. Emergency Visit Procedures

a. Priority of treatment:

(1) Coast Guard Active Duty assigned to floating units or in flight status.

(2) Other Coast Guard Active Duty.

(3) Active Duty of other services.

(4) Active Duty dependents.

(5) Retired Personnel.

(6) Dependents of retired personnel.

b. Dental records shall be retrieved as patients check in for emergency visits.

c. All patients shall have their records reviewed, dental health questionnaire completed (once ever 12 months) and BP recorded before being seen by a dental officer.

3. Appointment procedures

a. Utilize CHCS or DENCAS as a scheduler.

(1) Include patient’s name, status, phone and procedure when appointing.

(2) Give appointed patient a written appointment slip and/or an electronic reminder.

(3) Recommend scheduling at least 6 weeks in advance.

b. Failed appointments (including cancellations less than 48 hours before). Whenever practically possible, the SDO should be consulted,

regarding failed appointment status determination:

(1) Active duty- Clinic administrator is responsible for notifying patient’s supervisor and/or command on a case-by-case basis.

(2) Dependents & Retirees- services (except for emergency dental care) may be terminated.

c. Patients more than 10 minutes late may be re-appointed.

(1) Check with appropriate dental officer before rescheduling appointment.

d. Prior to end of each workday, assigned dental personnel will print next day’s schedule and provide copy to records technician for timely delivery of records to dental clinic. A copy of the daily schedule should be available to each provider and technician.

e. Ensure a DEERs check is done before making appointment for dependents.

f. Return patient records to records technician at end of each day.

g. Dental Recalls:

(1) All active duty personnel are required to have an annual dental examination.

(2) When possible, electronic automated reminders of upcoming dental appointments will be utilized.

(3) Patients are recommended to have annual exams done during their birth month to coincide with Periodic Health Assessment (PHA).

(4) Assigned dental personnel shall monitor dental readiness using DENCAS.

4. Medical Emergencies (including incapacitated provider protocol)

a. Medical emergencies occur infrequently within the dental clinic. However, their consequence may be life threatening, so clinic personnel must be prepared.

b. In the event of a medical emergency of a dental patient in the dental clinic, the attending dental officer will remain with the patient and provide basic resuscitation and first aid if needed, including vital sign evaluation and airway/oxygen therapy. The attending HS/dental assistant or designee will call 911 if directed by the dental officer and will inform the Medical Officer (MO) immediately and return to the patient to assist the dental officer.

c. When the MO, medical support staff, and emergency cart arrive at the scene, the DO shall report the patient’s status to the MO. The MO will then assume charge of the patient.

d. Incapacitated Provider Protocol.

(1) If the dental officer or dentist providing services to the patient is incapacitated during a dental procedure, the attending HS/dental assistant will call for immediate assistance from the closest personnel. The dental assistant or designee will immediately inform the Medical Officer (MO) of the emergency. The dental assistant or trained designee will perform basic resuscitation if needed and first aid, including vital sign evaluation and airway/oxygen therapy.

(2) When the MO, medical support staff, and emergency cart arrive at the scene, the HS/dental assistant shall report the dentist’s status to the MO. The MO will then assume charge of the dentist.

(3) When the emergency with the dentist provider is stabilized, the HS/dental assistant will attend to the dental patient. If a dental officer is not available to complete the interrupted procedure or the HS/dental assistant is not able to place a temporary restoration, the dental patient may be referred to __________ (where) __________ for completion of the interrupted procedure or placement of a temporary restoration.

f. Periodic emergency drills will be conducted at the discretion of the SDO, at least semiannually.

5. After Hours Emergency

a. Dental emergencies consist of, but are not limited to, uncontrolled bleeding, uncontrollable pain, uncontrolled infection, or orofacial trauma and/or swelling.

b. The dental clinic is available for treatment of active duty dental emergencies, and emergencies by non-AD patients currently being treated by dental staff or dental externs. Other non-AD patients (are/are not) eligible for emergency care after hours (in the following situations). -

OR-

The dental clinic is not a source of after hours care. After hours emergency dental patients shall be directed to _____ (list here)_________.

c. Treatment of dental emergencies shall consist of attempts at relief of pain and suffering, including referral for emergency specialty care when appropriate.

d. Broken fillings, broken dentures, etc., in the absence of symptoms listed in 5.a, do not constitute dental emergencies. Patients with such complaints shall be advised to call the dental clinic the following morning to schedule an appointment. Comprehensive general dentistry shall be scheduled and delivered during the normal work day.

e. The local Clinic Administrator and SDE shall be notified of any patients requiring hospital admission.

f. Follow-up of emergency patients during the next work day is advisable.

g. Emergency dental care for Active Duty Service Members may be obtained from any civilian dentist if their participating dentist or DTF dentist is not readily available. However, follow-up care with a non-network dentist is not authorized. Active Duty Service Members who elect to receive non-covered services as part of an episode of emergency dental care are responsible for payment of those additional services. It is recommended that the Active Duty Service Member use a United Concordia network dentist for emergency dental care whenever possible. See ALCOAST 370/09.

6. Active Duty Referrals

a. Active duty service members who receive routine dental care from the dental clinic can be referred to either a DoD dental treatment facility or to a civilian dentist for specialty care through the United Concordia Active Duty Dental Plan.

b. The dental clinic will coordinate the referral and authorization for the

member. See ALCOAST 370/09 and addp-.

7. Dental Radiology

a. The SDO is responsible for:

(1) Compliance with all provisions of COMDTINST M5100.47, Chapter 7, Safety and Environmental Health Manual.

(2) Designation, in writing, of a Radiation Safety Officer, who must be a technically qualified person responsible for the daily operation of the radiation safety program. This person should have a basic knowledge of radiation safety practice and procedures.

b. Radiation Safety Officer Responsibilities:

(1) Ensure compliance with the personnel dosimeter quality assurance and personnel monitoring program per COMDTINST M5100.47, Chapter 7-E-7, Safety and Environmental Health Manual.

(2) Ensure all women of child bearing age are advised of the potential hazards of radiation exposure to unborn children as described in COMTINST M5100.47, Chapter 7-E-6, Safety and Environmental Health Manual. Such personnel are required to sign a statement they have been informed. A copy of that statement will be attached to the fourth quarter dosimeter report and retained in the health record.

(3) Maintain all personnel monitoring records and dosimetry reports.

(4) Review radiation reports for unusual exposures, investigating cause, and reporting conclusions to CG-1133 via HSWL SUPACT Field Office SDE.

(5) Ensure evaluation of dental diagnostic radiographic equipment by the Regional Radiological Health Representative (RHHR) at least once every two years.

(6) Ensure evaluation whenever:

(a) New radiographic equipment is installed.

(b) Existing radiographic equipment is moved to a different location.

(7) Maintain a maintenance file on all radiographic equipment in the dental clinic.

(8) Ensure “Ionizing Radiation” signs are posted where required.

(9) Post signs requesting that possibly pregnant patients notify technicians.

8. Digital Dental Radiology Protocol

a. Below is a sample of a digital dental radiology clinic protocol. Using this sample in developing the protocol will ensure that the protocol meets dental clinic needs while covering required topics. It will also ensure a standardized format among United States Coast Guard (USCG) digital dental radiology protocols. Specific policies and procedures themselves will necessarily vary by clinic and will need a more extensive explanation than used in this sample. Factors affecting local policies include clinic mission, beneficiary population, and budget constraints.

b. Designation of Responsibilities

(1) This protocol will facilitate the training of new personnel in dental department operations and serve as an information source when regular dental and/or radiology staff members are unavailable. The Dental Officer designated as responsible for digital dental protocol will review and update this manual at least annually.

(2) Designated Dental Officer Responsibilities

(a) Proper storage of all digital dental radiology equipment and supplies in the clinic.

(b) Inspection of all radiology supplies.

(c) All record keeping associated such as patient log, repeat analysis, and dental imaging reports.

(d) Train clinic staff in dental radiology procedures as needed.

(e) Review and update of dental radiology protocol.

(f) Inspection of all sensors, lead shields and aprons for defects. (g) Cleaning of radiology equipment.

(3). Dental Radiology Personnel Responsibilities

(a) Follow all procedures for Infection Control as outlined in COMDTINST M6000.1D series (Chapter 13 Medical Manual).

(b) Maintain dental radiology department cleanliness (clean all equipment and counter spaces with appropriate germicidal disinfectant).

(c) Perform all administrative duties of the dental department.

(d) Act as liaison and work in concert with the clinic radiology safety technician.

(e) Prepare orders for replenishment of supplies.

(f) Train all dental clinic personnel in radiology safety procedures.

(g) Perform weekly cleaning of the radiology equipment IAW the manufacturer’s directions.

(h) Follow HIPAA COMDINST regarding tracking of dental images sent to other clinics.

(4) Dental Record Quality Control

(a) When a patient is initially entered into the computer to have digital images recorded, the full last, full first name is entered. The Emplid of the patient should be entered without dashes or spaces. Initially, at the examination appointment, images do not have to be printed or stored on removable media. However, if time allows, the panorex should be printed. The panorex serves as a baseline for general diagnosis. Images (radiographs &/or photographs) are placed on CD-R media (not CDRW) or printed on photo-quality paper when a member departs the unit or leaves the Coast Guard.

(b) If using CD-R media, the patient name, last four numbers of the SS#, and image date is written with permanent marker on the CD surface. Images are added as they are taken at each facility (using “multisession” recording). When the disc cannot hold any more data, “FULL” is written on the disc. A thin vinyl CD holder should be used to hold the disc securely in the dental record. A notation is made in the dental record whenever digital images are taken and/or stored on a disc.

(c) If the dental record is unavailable (possibly during remote exams), images should be printed or stored on CD-R media and the examination paperwork should be placed in a sealed envelope with the appropriate confidentiality sticker on the front. The member will take this back to their unit. Alternatively, the examiners may elect to send records in bulk to the unit at a later date.

(5) Image Archiving Quality Control. Until a centralized image archiving system is available, it is important for images to remain on the local dental clinic computers. Backups of all computers must be performed daily, and all computers must have uninterruptible power supplies. Detailed procedures for backing up computers should be placed in the dental clinic SOP. Clinics should archive/backup all patient images until further direction from CG HQs. Archival hard discs and/or optical discs (CD-R or DVD-R) should be stored with other health records or in a secure location. Archiving procedures are subject to change when a centralized CG image storage solution is online.

(6) Quality Assurance

(a) Digital sensors must be properly calibrated. The panorex and intraoral sensors are calibrated upon initial installation. Follow the manufacturer’s recommendations for follow-up calibration. Exposure times for intraoral sensors must be determined for each patient size, recorded in the dental clinic SOP, and posted by all x-ray units or stored in the x-ray unit memory. Exposure times should be determined using a phantom jaw if possible. If not available, extracted teeth or a suitable substitute can be used. Panorex settings are stored for each patient size and determined at initial set.

(b) QIS (OPTIONAL): Quarterly Reject Analysis. Reject analyses are used to determine the causes for images being rejected. Information obtained from reject analyses aid in identifying opportunities to improve problem areas.

(c) Sample QIS Format

1. DDO will review all the rejected images to determine the cause for rejection. Enter the information into one or more of the following categories of the reject analysis log. The reject analysis log is a locally produced monthly form which should include at least the following information:

Date, Type of Radiograph, Name of Tech, Reason for Repeat, and % Total Reject Rate.

2. Count the total number of images used during the reject analysis period. Normally a one month period is sufficient for the quarterly reject analysis.

3. Record the number of images rejected in each category and calculates the total reject rate and reject rate for each category.

4. Strive to achieve a reject rate of 5% or less. A rate above 10% indicates a need for immediate corrective action.

(7) Miscellaneous Guidelines

(a) Avoid crimping or damaging sensor wiring and sensors.

(b) Inventory all sensors at the end of each day.

(c) Backup all computers at the end of the day to assure that all images are archived.

(d) Include all procedures in the dental clinic SOP, including detailed descriptions of the steps required to take intraoral and panoramic digital images. The SOP should be updated and reviewed by the designated dental officer and SDE, at a minimum, annually.

(8) Dental Radiology Sterilization and Disinfection Procedures

(a) Digital sensors will be covered with a disposable plastic sleeve.

(b) Sensors and aiming devices will be disinfected according to manufactures instruction.

(c) The panoramic unit has available disposable bite block covers to use for each patient.

9. Mercury Hygiene (refer to ADA "Best Management Practices for Amalgam Waste, )

a. Amalgam scrap shall be sanitized using the following procedure.

(1) Use a commercial vacuum line cleaning solution according to the manufacturer’s instructions to clean the vacuum line and amalgam trap.

(2) Flush lines with approximately 100cc (4-5 ozs.) of water to rinse cleansing solutions from scrap amalgam.

(3) Remove lid from amalgam trap and allow air to pass through the trap until the contents are dry (usually not more than 5 minutes).

(4) Inspect trap and remove tissue or large tooth fragments with a pair of cotton forceps. Place tissue debris in sharps container.

(5) Transfer contents of amalgam trap to a sealed amalgam storage container provided by contracted biohazard waste disposal company. Follow the biohazard’s company’s policy for handling and storage of amalgam scrap.

10. Dental Supply

a. The senior HS shall maintain the dental supply within the allotted budget and be responsible for ordering, stock maintenance, and distribution of supplies.

b. Priority of sources of supply:

(1) DSCP Prime Vendor

(2) Other federal sources

(3) Federal supply schedules

(4) Open purchase.

B. Treatment Protocols

1. Anxiolysis/ Minimal Sedation.

a. Definition/Goal/Indications/Dosing.

1) Definition. Anxiolysis or anxiolytic therapy is the diminution or elimination of anxiety. Also referred to as light or minimal sedation, it is a pharmacologically induced state of consciousness where the patient is awake, has decreased anxiety, retains the ability to independently and continuously maintain an airway, and respond normally to tactile stimulation and verbal command. Although cognitive function and coordination may be modestly impaired, ventilation, memory and cardiovascular function are unaffected. The drugs and/or techniques used should carry a margin of safety wide enough never to render unintended loss of consciousness. Further, patients whose only response is reflex withdrawal from repeated painful stimuli would not be considered to be in a state of minimal sedation. [American Dental Association, Guidelines for the Use of Sedation and General Anesthesia by Dentists, Oct 2007]

2) Goal. The goal is to create the most relaxed and comfortable appointment possible, while the patient remains awake and conscious.

3) Indications. Phobic or anxious patients; adjunct to achieving

profound local anesthesia; pronounced gag reflex; and prolonged procedures.

4) Dosing. The appropriate initial dosing of a single enteral drug is no

more than the maximum recommended dose (MRD) of a drug that can be prescribed for unmonitored home use.

5) Supplemental dosing. During minimal sedation, supplemental dosing is a single additional dose of the initial drug that may be necessary for prolonged procedures. The supplemental dose should not exceed one-half of the initial dose and should not be administered until the dentist has determined the clinical half-life of the initial dosing has passed. The total aggregate dose must not exceed 1.5x the MRD on the day of treatment.

b. Dental Officer Requirements.

1) At a minimum, meet the oral sedation requirements of the state (or states) in which they hold their license(s).

2) Must be granted supplemental clinical privileges in anxiolysis by COMDT (CG-11)

3) Must have completed an advanced education program accredited by the ADA Commission on Dental Accreditation that affords comprehensive and appropriate training necessary to administer and manage minimal sedation commensurate with these guidelines.

4) Officers who did not complete an accredited advanced education program must have successfully completed training to the level of competency in minimal sedation consistent with that prescribed in the ADA “Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students” or a comprehensive training program in moderate sedation that satisfies the requirements described in the Moderate Sedation section of the ADA “Guidelines for Teaching Pain Control and Sedation to Dentists and dental Students” which can be retrieved from the ADA website.

5) Must hold a current certification in Basic Life Support for Healthcare Provider.

6) A medical officer must be readily available during anxiolytic therapy.

7) Must ensure that medical and dental staff members assigned to a dental anxiolytic team understands and abides by CG anxiolytic protocols. Furthermore, the dentist must organize yearly team training in anxiolytic protocol reviews and patient management during dental anxiolytic therapy.

c. Routes of Administration. [American Dental Association, Guidelines for the Use of Sedation and General Anesthesia by Dentists, Oct 2007]

1) Enteral – any technique of administration in which the agent is absorbed through the gastrointestinal tract or oral mucosa (i.e. oral, sublingual). Only enteral anxiolytic techniques are permitted in Coast Guard clinics.

2) Parenteral – a technique of administration in which the drug bypasses the gastrointestinal tract (i.e., intramuscular, intravenous, subcutaneous). Parenteral anxiolytic administration is not permitted in Coast Guard clinics.

d. Risks.

(1) Potential for depression of protective reflexes.

(2) Difficulty in predicting absorption and efficacy of drugs when administered orally.

(3) Individual variation in response to the drugs.

(4) Differing standards of equipment and staffing.

(5) Wide variety of drugs and combinations of drugs.

(6) Possibility of excessive amounts of these drugs being used by the patient without notifying the dentist.

e. Patient Evaluation and Treatment Plan.

(1) Complete Medical History.

a. Only healthy or medically stable individuals as defined by the

American Society of Anesthesiologists (ASA) ( I, II) may be

considered for anxiolytic therapy in Coast Guard clinics.

b. Contraindications. Patients with significant medical problems (ASA III, IV) are not candidates for anxiolysis in Coast Guard clinics. These problems include but are not limited to: medically unstable patients (i.e. angina, diabetes); medically complex patients (uncontrolled hypertension, COPD/Asthma, sleep apnea); patients exhibiting adverse reaction to the sedation medication; pregnancy; low body weight; or multiple drug use.

(2) Dental History and Emotional Status.

(3) Comprehensive Exam (T-2) - including radiographs, diagnostic casts, if necessary, for a treatment plan. Blood pressure, pulse, and pulse oximetry readings must be taken and evaluated prior to initiating anxiolytic therapy.

(4) Discuss Anxiolysis/Pre-sedation work-up (medication dosage and use).

(5) Treatment Plan Presentation.

(6) Informed consent for the procedure and for the use of anti-anxiety sedation medications must be obtained.

(7) Prescribe/Dispense Medication.

(8) Patients receiving anxiolytic therapy should be scheduled for an early morning appointment.

f. Medications. Only the following Anxiolytic Therapy Agents are

permitted for use in Coast Guard clinics according to the protocol that

follows:

(1) Diazepam (Valium®) 5 mg - 10 mg

(2) Triazolam (Halcion®) 0.125 mg - 0.25 mg

Anxiolysis Protocol – for up to 2 hours of treatment on adults 18 and older

|Night Before ( p.o.) |1 hour Prior to Treatment (p.o.) |

| | |

|Diazepam 5 mg |Diazepam 5 to 10 mg |

| |or Triazolam 0.125 to 0.25 mg |

p.o.: Abbreviation meaning by mouth, orally

3) Anxiolytic Reversal Agent: Flumazenil (Romazicon®)

a) Flumazenil must be stocked in the clinic pharmacy and it must be readily available during anxiolytic therapy.

b) Flumazenil is for intravenous use only and should be administered by a qualified medical or dental provider . Flumazenil is compatible with 5% dextrose in water, lactated ringer's and normal saline solutions. It is recommended that flumazenil be administered as a series of small injections described (not as a single bolus injection) to allow the practitioner to control the reversal of sedation to the approximate endpoint desired and to minimize the possibility of adverse effects.

c) For the reversal of the sedative effects of benzodiazepines administered for conscious sedation, the recommended initial dose of flumazenil is 0.2mg administered intravenously over 15 seconds. If the desired level of consciousness is not obtained after waiting an additional 45 seconds, a further dose of 0.2mg can be injected and repeated at 60-second intervals where necessary (up to a maximum of 4 additional times) to a maximum total dose of 1 mg. The dosage should be individualized based on the patient's response, with

most patients responding to doses of 0.6mg to 1 mg.

d) Flumazenil (Romazicon®) is available in 0.1mg/ml injection in

5 and 10ml vials.

g. Pre-Operative Patient Instructions

(1) Take regular medications unless specified by your physician or dentist.

(2) Do not eat or drink for 8 hours prior to the dental appointment. Patients may take their anxiolytic medication with a small amount of water.

(3) Patient must be driven to the clinic by a responsible companion. The companion must remain in the clinic during the appointment.

(4) No drinking alcohol for 8 hours prior to the dental appointment.

h. Intra-Operative Protocols

(1) The qualified dentist is responsible for the anxiolytic management, adequacy of the facility and staff in terms of resuscitative management, diagnosis and treatment of emergencies related to the administration of minimal sedation and providing the equipment, drugs and protocol for patient rescue.

(2) Monitoring and Emergency equipment will be used.

a. Monitoring Equipment: A Welch Allyn Vital Signs Monitor ® or similar device used to monitor pulse, pulse oximetry, and Blood Pressure should be used.

b. Emergency Equipment: A positive pressure oxygen delivery system suitable for the patient being treated must be available; including an anaphylaxis kit.

c. Documentation of the dosages of drugs and the timing of their administration must be kept as a part of the patient’s record. Entries will also include the blood pressure, pulse, and pulse oximetry readings in fifteen minute intervals.

d. At least one additional person trained in Basic Life Support for Healthcare Providers must be present, in addition to the dentist, to monitor and document the BP, heart, respiratory function and oxygen saturation of the patient. This person must have previously completed in house training that includes, but is not limited to, the review and understanding of Coast Guard anxiolysis protocols.

e. If a patient appears to enter a deeper level of sedation, the dentist must stop the dental procedure and assess the need for a calling a medical officer and for possible use of a reversal agent. The dentist should proceed with dental treatment only when the patient returns to the intended level of sedation.

i. Post-Operative Patient Instructions (verbal and written for Patient and Escort)

(1) Take all regular or prescribed medications.

(2) No alcohol for 12 hours post-operatively.

(3) No driving for 12 hours post-operatively.

(4) Do not operate machinery for 12 hours post-operatively.

(5) No stimulants for 12 hours post-operatively.

(6) Must have a responsible companion drive patient home and observe recovery.

(7) Phone number where dentist can be reached must be provided to patient.

(8) Stay hydrated – drink lots of water.

(9) Non-steroidal anti-inflammatories may be used as needed.

(10) A member of the dental anxiolytic staff shall contact the patient the following day for a progress report.

2. Implants

a. Background.

Evidence based research including peer reviewed literature reviews support the quality, success and necessity for dental implant restorations as an excellent treatment planning modality. Dental implants are a statistically successful restorative option for edentulous sites in the maxilla and mandible. This prosthetic dental treatment is valuable in restoring our United States Coast Guard (USCG) members to improved function as well as a standard of care in treatment planning where esthetic options are of great concern. This requires a team approach by credentialed providers, either by dentists within the Coast Guard dental program, military treatment facilities or by civilian referrals or contracted specialists and general dentists who provide such specialty treatment. This complex treatment option will be a commitment to long-term

maintenance with similarly long lasting ramifications upon our USCG

members. These include potentially expensive services that will continue to exist long after the members have left USCG service. Hence, treatment planning for our USCG members to receive such complex and expensive treatment (with the understandable complex and lifelong maintenance requirements) must be carefully considered in weighing this treatment modality with conventional and more conservative fixed and /or removable prosthodontic treatment regimens.

b. Location of treatment facilities.

The USCG utilizes a multitude of processes for members to receive implant treatment planning and implant treatment. The processes include the use of military treatment facilities (MTF’s) in which all implant treatment may be provided in the same facility, similar to TRACEN Cape May where the USCG has specialists in one large dental facility. In addition, civilian contract general dentists and/or referred civilian specialists may provide implant treatment for USCG members with proper referral and evidence of treatment planning to include final restoration and follow on care. Coast Guard members may be referred for implant treatment planning and treatment to these MTF’s, large multispecialty dental offices or a combination of both with coordination of care regarding the treatment plan. Dental officers and dentists should utilize network providers within the active duty dental plan administered by United Concordia.

c. Steps for Implant Treatment Planning.

(1) Team approach to care.

(2) Thorough medical history, diagnosis, and treatment planning.

(3) Consideration of alternative, conventional therapies

(4) Patient education, consent, and assurance of commitment including rotation dates during pre- surgical, post-surgical, restorative, and follow on care.

(5) Strict adherence to surgical protocols.

(6) Adequate healing periods and progressively loading when appropriate.

(7) Precision fabrication and delivery of restoration(s).

(8) Axial loading-minimized lateral forces.

(9) Restoration designed for ease of hygiene.

(10) Scheduled follow on care.

(11) Availability of care consistent with resources and mission of the facility.

d. Patient Selection Criteria

(1) Priority- only active duty USCG members will be considered for implant restorations at Coast Guard expense.

(2) Rotation dates or release from active duty- eighteen (18) months is recommended from treatment planning to placement of final restoration.

(3) General health- patient must be free of significant systemic or local disease.

(4) Oral health status- all routine dental care and definitive periodontal therapy must be completed prior to implant placement. Patients must exhibit and maintain adequate oral hygiene.

(5) Contraindications-general contraindications to implant treatment include but are not limited to:

(a) Tobacco use within 1 year.

(b) Therapeutic radiation in immediate areas of potential implant sites.

(c) Metabolic bone diseases, debilitating or transmissible hepatitis, acquired immune deficiency virus (AIDS).

(d) Medications that might affect healings, drug and/or alcohol dependency.

(e) Poorly controlled Type I or II diabetes mellitus.

e. Implant Placement

(1) Civilian providers outside a CG facility-must be approved by the Dental Service Point of Contact (DSPOC) for the Active Duty Dental Plan (ADDP).

(2) CG Dental Officers/Civilian Providers within the CG facility-only board certified periodontists or prosthodontists will place implants.

f. Implant Restoration

(1) CG Dental Officers/Civilian Providers within the CG facility must have evidence of Implant Restoration training and be privileged for implant restoration.

(2) Civilian providers outside a CG facility-must be approved by DSPOC.

g. Implant systems

Noble Biocare and/or 3i systems are recommended in alignment with DoD usage.

3. Preventive Dentistry Program

a. The SDE will appoint a preventive dentistry officer or oversee a preventive dentistry program. Dentists should view the website: , for the latest information on evidenced based dentistry.

b. Optimal water fluoridation is recommended to all active duty members and fluoride supplements prescribed as appropriate. Dentists should view the website: , for the latest information on fluorides.

c. Sealants shall be applied as appropriate. Dentists should view the website: , for the latest information on sealants.

4. Prosthodontic Dentistry

a. The dental clinic will provide indicated prosthodontic care to beneficiary’s on a space available basis.

b. Prosthodontic care will generally not be provided to individuals who have demonstrated an inability to care for potential abutment teeth.

c. Prosthodontic appliances will not be prepared or placed in the presence of active periodontal disease.

d. Prosthodontic care for non active duty patients shall be performed only if all active duty needs have been met. Dependents of active duty personnel are responsible for the cost of any laboratory services their treatment incurs.

e. All prosthodontic prescriptions shall be completed and signed by a dental officer.

5. Treatment of Aviation Personnel (See reference COMTINST M6410.3)

a. All medical officers, dental officers and health services technicians have the authority to issue a grounding notice, when appropriate.

b. When a flight surgeon (FS) or aviation medical officer (AMO) is not available to recommend an up-chit, an MO or HS may issue an up- chit (CG Form 6020) after verbal concurrence has been obtained from an FS or AMO.

c. With exceptions explained below, all groundings require an up-chit before personnel can resume aviation duties. The clinical situations listed below are exceptions to this policy. Automatically expiring grounding chits may be granted only by appropriate authorities. It should be emphasized to active duty personnel that they have the obligation to report problems and conditions following any type of care to appropriate health care personnel prior to resuming aviation duties.

d. Immunizations: Personnel may resume aviation duties, if symptom free, 12 hours after the immunization(s) are administered.

e. Short acting dental anesthesia: Personnel may resume aviation duties, if symptom free, 6 hours after the administration of anesthesia.

f. Long acting dental anesthesia: Personnel may resume aviation duties, if symptom free, 12 hours after the procedure.

g. The DO may issue automatically expiring grounding chits (CG Form 6020) for the simple procedures described above. This will be noted on the SF 603/603A along with the time of administration of the anesthetic. The grounded block on the Status Profile form will be checked and the recommended time of expiration noted in the limited duty block.

h. For more extensive dental treatment, the DO will issue a non-expiring grounding notice and will complete the limited duty or not fit for duty block, as indicated, on the Status Profile form. These patients, will be given an appointment for follow-up assessment and when appropriate, and issuance of an up-chit.

i. Administration of a short active local anesthetic, such as lidocaine or mepivicaine, incurs a minimum of a 6 hour automatically expiring grounding notice. Use of longer acting local anesthetics such as bupivicaine requires at least a 12 hour automatically expiring grounding notice.

j. Oral surgery and/or periodontal surgery involving dressings and/or sutures, incision and drainage require a 72 hour grounding notice.

Aviation personnel may be returned to duty sooner if granted an up chit by a FS or AMO.

k. Grounding of aviation personnel due to a dental condition should be based on the dental officer’s assessment of the potential for the patient to become symptomatic prior to or as the result of treatment.

6. Treatment of Minors

a. Dependent children below the age of __ (insert age based on local state requirements) ___ shall be accompanied by a custodial guardian for consent to treatment.

b. An informed consent shall be obtained before evaluation

C. Administrative

1. Leave and Liberty

a. Leave is granted with the permission of the SDO/SHSO through the chain of command.

b. Special liberty is granted with the approval of the SDO/SHSO through the chain of command.

2. Dental Extern Program

a. The Dental Extern Program is governed by the Student Extern

Program, COMDTINST 6400.1B, dated Mar. 2009. In addition to logistical information, COMDTINST 6400.1.B requires that preceptors maintain adequate levels of supervision of externs and monitor the appropriateness of care provided by externs as follows:

(1) Externs shall receive preceptors’ approval before the initiation of any treatment (including the administration of local anesthesia).

(2) Externs’ restorative and endodontic preparations will be evaluated by preceptors before completion.

(3) Externs will not dismiss the patients until the final restoration is approved by the preceptor.

(4) Externs will perform oral surgery only under the direct supervision of preceptor or designated DO.

(5) Externs’ health record entries will be checked daily for accuracy and completeness by preceptors.

(6) Externs’ pharmacy and laboratory prescriptions will be countersigned by a DO.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download